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IN HIS NAME

IN HIS NAME. Surgery or colonoscopy???. That is the problem!!!! . INTRODUCTION. Acute colonic pseudo-obstruction (ACPO) is characterised by massive colonic dilation with symptoms and signs of colonic obstruction without mechanical blockage

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IN HIS NAME

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  1. IN HIS NAME

  2. Surgery or colonoscopy??? That is the problem!!!!

  3. INTRODUCTION Acute colonic pseudo-obstruction (ACPO) is characterised by massive colonic dilation with symptoms and signs of colonic obstruction without mechanical blockage Ischemia and perforation are the feared complications of ACPO

  4. INTRODUCTION • Ischemia and perforation are the feared complications of ACPO • Spontaneous perforation has been reported in 3%–15% of cases with a mortality rate estimated at 50% or higher when this occurs . • The main issues for the clinician to consider are: (1) what is the correct diagnosis? (2) Is ischemia or perforation present? (3) What is the appropriate evaluation and management?

  5. PATHOGENESIS • Colonic pseudoobstruction was first described in 1948 by Sir Heneage Ogilvie, who reported two patients with chronic colonic dilation associated with malignant infiltration of the celiac plexus. • An imbalance in autonomic innervation, produced by a variety of factors, leads to excessive parasympathetic suppression or sympathetic stimulation

  6. Predisposing factors • In comparison to control patients, patients who developed ACPO had significantly lower postoperative serum sodium, a higher serum urea and remained in hospital longer

  7. CLINICAL PRESENTATION • ACPO most often affects those in late middle age (mean of 60 years of age), with a slight male predominance (60%) • ACPO occurs almost exclusively in hospitalised or institutionalised patients with serious underlying medical and surgical conditions. Abdominal distention usually develops over 3–7 days but can occur as rapidly as 24–48 h.7 In surgical patients, symptoms and signs develop at a mean of 5 days postoperatively.

  8. clinical features • abdominal distention (80 %) • abdominal pain (80%) • nausea and/or vomiting (60%) • Passage of flatus or stool is reported in up to 40% of patients • high incidence of fever inpatients with ischemic or perforated bowel

  9. DIAGNOSIS • suggested by the clinical presentation and confirmed by plain abdominal radiographs, which show varying degrees of colonic dilation • The right colon and cecum show the most marked distention, and ‘cutoffs’ at the splenic flexure and descending colon are common

  10. MANAGEMENT

  11. outcome

  12. outcome • spontaneous perforation to be approximately 3%. • The risk of colonic perforation has been reported to increase with cecal diameter greater than 12 cm and when distention has been present for more than 6 days • A two-fold increase in mortality occurs when cecal diameter is greater than 14 cm and a fivefold increase when delay in decompression is greater than seven days.

  13. Treatment • Treatment options for ACPO include appropriate supportive measures, pharmacologic therapy, colonoscopic decompression, and surgery

  14. Supportive therapy

  15. Treatment • patients with marked cecal distention (>10 cm) of significant duration (>3–4 days) and those not improving after 24–48 h of supportive therapy are candidates for further intervention

  16. Medical therapy • Neostigmine: • a reversible acetylcholinesteraseinhibitor • administered intravenously, • has a rapid onset of action(1–20 min) • short duration (1–2 h) • The elimination half-life averages 80 min

  17. Neostigmin • Contraindications to its use include mechanical obstruction,presence of ischemia or perforation, pregnancy, uncontrolled cardiac arrhythmias, severe active bronchospasm, and renal insufficiency (serum creatinine >3 mg/dL).

  18. Colonoscopic decompression • Colonic decompression is the initial invasive procedure of choice for patients with marked cecal distention (>10 cm) of significant duration (>3–4 days), not improving after 24–48 h of supportive therapy, and who have contraindications to or fail neostigmine. • It should not be performed if overt peritonitis or perforation are present

  19. Colonoscopic decompression • there are case reports of patients with ischemia in ACPO being successfully managed with colonoscopicdecompression • Oral laxatives and bowel preparations should not be administered prior to colonoscopy • Prolonged attempts at cecal intubation are notnecessary because reaching the hepatic flexure usually suffices

  20. Colonoscopic decompression

  21. Colonoscopic decompression • Efficacy • successful colonoscopic decompression has been reported in many retrospective series • In the series reported by Geller et al: Acute colonic pseudo-obstruction was diagnosed in 50 patients; . Forty-one patients (82%) had one colonoscopic decompression with clinical success in 39 (95%). Nine patients (18%) required multiple (2 to 4) colonoscopic decompressions with clinical success in 5 (56%)

  22. Colonoscopic decompression • the overall clinical success of colonoscopic decompression was 88%. However, in procedures where a decompression tube was not placed the clinical success was poor (25%).

  23. Colonoscopic decompression • Safety: • The complication rate of decompression colonoscopy in ACPO ranges from approximately 1 to 5% • Perforation is the most complication

  24. Percutaneous cecostomy • can be considered in high surgical risk patients • reserved for patients failing neostigmine and colonoscopic decompression who have no evidence of ischemia or perforation and who are felt to be at high risk for surgery.

  25. Surgical therapy • Surgical management is reserved for patients with signs of colonic ischemia or perforation or who fail endoscopic and pharmacologic effort • Without perforated or ischemic bowel, cecostomy is the procedure of choice. • In cases of ischemic or perforated bowel,segmentalor subtotal resection is indicated

  26. Everyone can enjoy of life but just some of them can pick up a scalple and save the lifes.

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